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Ashtauninditiya Adhyaya (view source)

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=== Introduction ===

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== Introduction ==

Charak has laid down the foundation of genetic/hereditary and endocrinal disorders in relation to four pairs of opposing (and undesirable) physical characteristics- height (too tall, too short), body hair (too hairy, hairless), complexion (too dark, too light), and body mass (too obese, too lean). Among these, ''atisthula'' (morbid obesity) is the most undesirable characteristic because it is associated with several life-threatening complications including diabetes, hypertension, coronary artery diseases, joint disorders, skin disorders, anorectal problems, etc. This chapter focuses on the features of a healthy physical constitution of a person, definitions of sleep, as well as key concepts associated with disease management such as etiopathogenesis, clinical presentation, prognosis, and management of ''atisthula''. Some key etiological factors of ''atisthula'' include dietary and lifestyle indicators (e.g., sedentary habit and high-calorie diet), and genetic and hereditary factors. This chapter also describes the pathogenesis of ''atisthula'' in detail, involving ''rasa'' (plasma) and ''meda'' (adipose tissue) as important ''dushyas'' (affected tissues). Modern medicine has acknowledged the role of ''meda'' (adipose tissue) as a principal ''dushya'', with obesity and dyslipidemia regarded as the main components of the basic matrix of this disease and its related disorders<ref name=ref1>Pandey A. K and Singh R. H.: “A Study of the Immune status in patients of diabetes mellitus and their Management with certain NaimittikaRasayana drugs”, JRAS. Vol. XXIV. No. 3-4, 2003; 48-61. </ref> <ref name=ref2>Pandey A.K and Singh R.H. (2012): A Clinical Study on Certain Diabetic Complications under the Influence of Naimittika Rasayana Therapy w.s.r. to Nishamalaki and Shilajatu), PhD. Thesis, Department of Kayachikitsa,, IMS, BHU, Varanasi. </ref> <ref name=ref3>Jaspreet Singh & A. K. Pandey: Clinical Evaluation of Pushkaramula (Inula racemosa) Capsule in the patients of Metabolic syndrome”, International Journal of Medicine and Pharmaceutical Sciences (IJMPS), ISSN(P): 2250-0049; ISSN(E): 2321-0095, Vol. 4, Issue 2, Apr 2014, 9-20. </ref>. The recent concept of “metabolic syndrome” was already recognized in [[Ayurveda]]. Biomedical science points that overweight individuals experience greatly elevated morbidity and mortality from various ailments including cardiovascular diseases<ref>National Institutes of Health. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: the evidence report. Bethesda, Md: National Heart, Lung, and Blood Institute and National Institute of Diabetes and Digestive and Kidney Diseases; 1998. </ref> <ref>Alpert MA. Obesity cardiomyopathy: pathophysiology and evolution of the clinical syndrome. Am J Med Sci. 2001;321: 225–236.</ref>

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===Sanskrit text, transliteration and english translation===

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==Sanskrit text, transliteration and english translation==

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~~We shall now~~ explain the chapter on ~~the~~ eight undesirable physical appearances.

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Now I will explain the chapter on eight undesirable physical appearances. Thus said Lord Atreya [1-2]

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Thus said Lord Atreya [1-2]

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==== Eight undesirable physical appearances ====

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=== Eight undesirable physical appearances ===

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In the context of the body (structure and appearance), the following eight types of persons are considered undesirable - too tall, too short, too hairy, hairless, too dark, too light (complexioned), too obese and too lean [3]

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==== Eight inherent sequelae of obesity ====

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=== Eight inherent sequelae of obesity ===

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Amongst these, the too obese and too lean physical appearances are considered the most undesirable ones. The excessively obese have eight inherent defects in them: reduced lifespan, constricted or limited movement (hampered due to loose, tender and heavy fats), reduced sexual activities or impotence (due to small quantity of semen produced and obstruction of the channel of semen by ''medas''), debility (due to ''dhatu'' imbalance), emit bad smell (due to the inherent nature of fatty tissues as well as excessive sweating), profuse sweating (since ''medas'' and ''kapha'' are vitiated), and excessive hunger and thirst (due to excessive digestive ''agni'' and ''vayu'' in the body). Excessive obesity is caused due to over-nourishment as a consequence of the intake of heavy, sweet, cold and fatty diet, lack of physical exercise, abstinence from sexual intercourse, sleeping during the day, uninterrupted cheerfulness, lack of mental activities and hereditary/genetic defects. These consequences may lead to an excess of fat (with further accumulation of only fat) and consequent depletion of dhatus. [4]

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==== Pathophysiology of Obesity ====

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=== Pathophysiology of Obesity ===

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Due to the obstruction of body channels by ''medas'', the movement of ''vata'' is specially confined to ''koshtha'' (abdominal viscera) resulting in the stimulation of digestive power and absorption of food. Hence,the person digests food quickly and becomes a voracious eater. By not following rules of taking meals at specific times during the day, he is afflicted by dreadful diseases. ''Agni'' (''pitta'' component responsible for digestion) and ''vata'' are the two most troublesome factors from the standpoint of obesity. These factors blight an obese person as wildfire destroys a forest. As the body gains excessive fat, vitiated ''doshas'' suddenly cause severe diseases resulting in rapid deterioration of life. The person is considered too obese when there is an excessive increase in fat and muscle tissue in the regions of buttocks, abdomen, and breasts, which become pendulous and suffer from deficient metabolism and energy. These are the causes, signs, and symptoms of an obese person [5-10]

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==== Features of an excessively lean person ====

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=== Features of an excessively lean person ===

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Both these undesirable types of people (too obese and too lean) always suffer from some disease or the other and need to be constantly managed by bulk-reducing and bulk-promoting therapies respectively. Of the two, lean is less harmful than obese, and the physical and mental sufferings in the case of an obese person are far greater in comparison to a lean person [16-17]

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==== The importance of ideal body proportion ====

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=== The importance of ideal body proportion ===

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A person with a balanced proportion of muscles and compactness of the body and firmness in sense organs is not overcome by the onslaught of disorders. Such people can tolerate hunger, thirst, the heat of the sun, cold and physical exercise. Their digestion, assimilation of food and muscle metabolism is in a state of equilibrium. [18-19]

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==== The best diet for obese and lean persons ====

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=== The best diet for obese and lean persons ===

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Heavy and non-nourishing (diet) therapy are prescribed for slimming in the case of the too obese, while for promoting the bulk of the too lean light and nourishing therapy is prescribed [20]

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==== Management of obesity ====

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=== Management of obesity ===

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One desirous of reducing obesity should indulge more and more in vigil, sexual activities, as well as physical and mental exercises [21-28]

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==== Management of leanness ====

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=== Management of leanness ===

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Besides, freedom from anxiety about any work, intake of nourishing diet and adequate sleep makes the man too obese like a pig [29-34]

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==== Sleep physiology ====

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=== Sleep physiology ===

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An individual falls asleep when his mind including the sensory and motor organs get exhausted, and they dissociate themselves from their objects. [35]

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==== Benefits of sleep ====

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=== Benefits of sleep ===

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In human beings, happiness and misery, nourishment and emaciation, strength and weakness, fertility and infertility, knowledge and ignorance, and life and death depend upon proper (and improper sleep). Untimely, excessive sleep and sleep deprivation take away both happiness and longevity from a person. Similarly, proper sleep brings about happiness and longevity in human beings just as real knowledge brings about spiritual power in yogis [36-38]

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==== Indications of daytime sleep ====

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=== Indications of daytime sleep ===

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Sleeping during the day is advocated for those who are exhausted on account of singing, reading, alcoholic drinking, sexual intercourse, elimination therapy, carrying heavy weight, walking long distances, suffering from phthisis, wasting, thirst, diarrhea, colic pain, dyspnea, hiccup, insanity, or are too old, too young, weak and emaciated. It is also recommended for those who are injured by fall and assault or exhausted by travel-related stress, vigil, anger, grief, and fear. By this, equilibrium of ''dhatus'' and strength is maintained, and ''kapha'' nourishes the body parts and ensures longevity. In the summer season, nights become shorter, and ''vata'' gets provoked in the body in ''adanakala'' (seasons of low body strength, such as summer and rains) due to absorption of fluid. Therefore, during this period daytime sleeping is advocated for all [39-43]

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==== Consequences of improper daytime sleep ====

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=== Consequences of improper daytime sleep ===

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Sleeping during daytime is contraindicated in the seasons other than summer because it causes vitiation of ''kapha'' and ''pitta''. Persons having excessive fat, those who are addicted to fatty substances, having plenty of ''kapha'', suffering from vitiated ''kapha'' related disorders, and those afflicted by latent poisons should never sleep during daytime. If one violated the given advice of sleeping during the day, he would subject himself to ''halimaka'' (advance stage of jaundice), headache, cold, heaviness of body parts, malaise, loss of digestive power, ''hridyopalepa'' (a feeling as if phlegm adhered to the heart), edema, anorexia, nausea, rhinitis, hemicranias, urticarial patches, pustules, boils, itching, drowsiness, coughing, disorders of the throat, impairment of memory and intelligence, obstruction of the body channels, fever, incapability of sensory and motor systems and enhancement of the toxic effects of poisons. So, one should keep in view the merits and demerits of sleep in various seasons and situations to stay happy and live long [44-49]

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==== Qualities of day and night sleep ====

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=== Qualities of day and night sleep ===

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Insomnia or staying up late at night causes roughness in the body and sleeping during the day causes ''snigdhata'' (unctuousness). However, napping in sitting posture does not cause either roughness nor unctuousness [50]

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==== The importance of diet and sleep among the obese and the (excessively) lean ====

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=== The importance of diet and sleep among the obese and the (excessively) lean ===

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As wholesome diet is essential for the maintenance of the body, sleep is essential for happiness. Therefore, obesity and leanness are specifically caused by improper sleep and diet. [51]

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==== Sleep-promoting measures ====

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=== Sleep-promoting measures ===

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If for some reason one suffers from sleeplessness, he can be cured by applying measures such as- body massages, unction, bath, (intake of) soup made up of meat of domestic, marshy and/or aquatic animals, ''shali'' rice with curd, milk, fat, wine, mental pleasure, pleasant smell and sound, application of soothing ointment to eyes, head and face, comfortable bed and home, and getting habituated to sleeping at a particular time. [52-54]

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==== Causes of sleeplessness ====

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=== Causes of sleeplessness ===

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The above-mentioned factors, along with overwork, old age, ''vatika'' diseases, ''vatika'' constitution and aggravation of ''vata'' itself, are known to cause sleeplessness even in a normal individual. Some are insomniac even by nature [55-57]

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==== Origins and types of sleep ====

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=== Origins and types of sleep ===

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Natural sleep (sleeping at night) is the best form of sleep. This is also known as ''Bhutadhatri'', or “that which nurses all the living beings." The form of sleep that is caused by ''tamas'' is the cause of all sinful acts while the remaining types are observed in specific situations and ailments [59]

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==== Summary ====

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=== Summary ===

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*Types and effects of sleep [60-62]

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=== ''Tattva Vimarsha'' / Fundamental Principles ===

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== ''Tattva Vimarsha'' / Fundamental Principles ==

*Eight types of the undesirable appearance of humans are: too tall, too short, too hairy, hairless, too dark, too light (complexioned), too obese and too lean. Too obese and too lean are the most undesirable of human appearances that are also more prone to various diseases. [3]

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*Obesity and leanness are caused by improper diet and sleep. [51]

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=== ''Vidhi Vimarsha'' / Applied Inferences ===

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== ''Vidhi Vimarsha'' / Applied Inferences ==

In biomedical science, the above-described eight types of undesirable persons are comparable to a variety of genetic and neuroendocrine disorders. Out of these eight types, the last two (''atisthula'' and ''atikrisha'') need therapeutic interventions and deserve special attention. According to Chakrapanі, physical deformities such as ''kubja'' (hunchback) and ''pangu'' (limp gait) may also be taken as undesirable.

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==== Too Obese ====

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=== Too Obese ===

In the context of ''atisthula'' and ''atikrisha'', Charak has explored these conditions from the standpoint of their diathesis, clinical presentation, and management, which is comparable to approaches taken today to the study of obesity and leanness. Suśruta has considered ''rasa dhatu'' as the main culprit for both obesity and emaciation (''rasa nimittameva sthaulyam karshyam ca'')<ref>Acharya, J.T. (translator) (1915). Sushrut Sanhita of Sushrut, Nirnay Sagar Press, Mumbai, India, p. 65, Su.Su-15/39. </ref>.

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Lipid precursors are acted upon by fat-specific energy (''medhodhatvagni'') for their conversion into adipose tissue (''medodhatu'')<ref>Mishra, L.C. (2003). Scientific Basis of Ayurvedic therapy, Chapter 9 Obesity (Medoroga) in [[Ayurveda]]; eBook, published by CRC press, Taylor & Francis Group. </ref>. Vitiation of ''kapha dosha'' and excessive accumulation of fat-specific energy and waste products of adipose tissues (''kleda'') lead to dysfunction of adipose tissues. Adipose channels have two origins - kidney, adrenal and fat around them and other are visceral and omental fat (''vapavahana'')<ref>Shastri, P.K (1983), (translater), Caraka samhita, Part I, 2nd ed., Chaukhambha Sanskrit Sansthan, Varanasi, India, p. 595. </ref>. These channels draw nutrition, including lipid from the antecedent flesh and transient lipid and then convert them into a stored form of lipid. As per biomedical science, obesity is associated with increased adipose stores in the subcutaneous tissues, skeletal muscles and internal organs such as kidney, heart, liver and omentum. Adipose tissues (''medodhatu'') form a crucial link to the concept of tissue metabolism. Low levels of fat-specific energy (''medodhatvagni''), despite a normal food intake, can lead to a steady accumulation of fat and the outcome is obesity<ref>Bleich S, Cutler D, Murray C, Adams A (2008). "Why is the developed world obese?". Annu Rev Public Health29: 273–95. doi:10.1146/annurev.publhealth.29.020907.090954. PMID 18173389. </ref> <ref>Drewnowski A, Specter SE (January 2004). "Poverty and obesity: the role of energy density and energy costs". Am. J. Clin. Nutr.79 (1): 6–16. </ref>. The conventional system of medicine has given due consideration to certain factors such as insufficient sleep, genetic predisposition, later age pregnancy, certain medications and other epigenetic factors in the etiopathogenesis of obesity and its related disorders<ref>Keith SW, Redden DT, Katzmarzyk PT et al. (2006). "Putative contributors to the secular increase in obesity: Exploring the roads less traveled". Int J Obes (Lond)30 (11): 1585–94. doi:10.1038/sj.ijo.0803326. PMID 16801930. </ref>.(Verse 3-4)

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==== Increased desire to eat among the obese ====

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=== Increased desire to eat among the obese ===

Charak correlated an increased desire to eat with increased ''agni'' in the morbidly obese. Recent evidence suggests that leptin and ghrelin had shown their influence on appetite. In this context, ghrelin is produced from the stomach, and leptin is produced by the adipose tissue of fat storage reserves in the body, which is responsible for short-term and long-term appetite control respectively in the body<ref>Hamann A, Matthaei S (1996). "Regulation of energy balance by leptin". Exp. Clin. Endocrinol. Diabetes104 (4): 293–300. doi:10.1055/s-0029-1211457. PMID 8886745. </ref>. In the brain melanocortin pathway has drawn the attention of research scholars that this pathway has a specific role in stimulating appetite, which is located in the area of the lateral and ventromedial hypothalamus and arcuate nucleus. These areas are directly related to the feeding and satiety centers<ref name=ref30>Rao CR, Sen PK, Flier JS (2012). Handbook of Statistics: Bioinformatics in Human Health and Heredity; Published by North Holland; 1 edition, Kindle Edition, 1 edition. </ref> .

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There are two distinct groups of neurons in the arcuate nucleus viz- The first group contains neuropeptide Y (NPY) and agouti-related peptide (AgRP) and the second group contains Pro-opiomelanocortin (POMC) and cocaine and amphetamine regulated transcript (CART). The first group of neuron i.e. NPY/AgRP exerts stimulatory inputs to the LH while inhibitory inputs to the VMH, which stimulate feeding and inhibit satiety respectively. Both groups of arcuate nucleus neurons are the under the regulation of leptin, which inhibits the NPY/AgRP group of neurons and stimulating the POMC/CART group of neurons. Hence, the leptin deficiency or leptin resistance leads to develop overfeeding tendency, which is caused by some genetic and acquired forms of obesity<ref name=ref30/>Rao CR, Sen PK, Flier JS (2012). Handbook of Statistics: Bioinformatics in Human Health and Heredity; Published by North Holland; 1 edition, Kindle Edition, 1 edition. </ref> <ref>Raina GS (2011). Obesity being the major health burden needed to be chased: A systemic review. J Appl Pharm Sci. 2011;1:238–45. </ref>. These findings suggest the genetic inputs in overweight and obesity, which is quite comparable to the Ayurvedic lexicons.(verse 4)

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==== Consequences of obesity (verse 5-8) ====

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=== Consequences of obesity (verse 5-8) ===

Serious diseases (''daruna vikara'') are the outcome of excessive obesity due obstruction of body channels by the ''medas''. This indicates ancient wisdom of [[Ayurveda]] ''acharyas'', which is comparable to the impact of obesity on health perspectives of biomedical science<ref>Mishra, L.C. (2003). Scientific Basis of Ayurvedic therapy, Chapter 9 Obesity (Medoroga) in [[Ayurveda]]; eBook, published by CRC press, Taylor & Francis Group. </ref>. We have yet to understand what they had foreseen in reference to fat accumulation around the kidneys. Decreased life span (''ayukshaya'') is stated to be an important consequence of obesity in [[Ayurveda]]. According to contemporary science, metabolic and psychological pathologies are often present together and are associated with dysregulation of the hypothalamic-pituitary-adrenal axis<ref>Boulpaep, Emile L.; Boron, Walter F. (2003). Medical physiologya: A cellular and molecular approach. Philadelphia: Saunders. p. 1227. ISBN 0-7216-3256-4 </ref>. Affect disorders are also reported among obese binge eaters. The National Institute of Health, USA has issued an alert labeling obesity a "Killer disease" due to its health-related consequences such as coronary disease, diabetes mellitus, hypertension, hyperlipidemia, kidney disorders, gallbladder disorders, cancer of colon, pancreas, breast, uterus, kidney and gallbladder, osteoarthritis, menstrual irregularities in females, cryptogenic cirrhosis of the liver and hepatocellular carcinoma, insulin resistance, and physiological hyperinsulinemia. Some of the social consequences of obesity could include divorces, due in part to reduce sexual activities between partners. Besides there, transitional physiological phases such as weight gain during adolescence in boys and girls, post-natal weight gain in women, and peri-post menopausal obesity are frequently noted in clinical settings that warrant special care and management<ref> Kuniko Takagi, Romain Legrand, Akihiro Asakawa, Haruka Amitani, Marie François, Naouel Tennoune, Moïse Coëffier, Sophie Claeyssens, Jean-Claude do Rego, Pierre Déchelotte, Akio Inui, Sergueï O. Fetissov. Anti-ghrelin immunoglobulins modulate ghrelin stability and its orexigenic effect in obese mice and humans. Nature Communications, 2013; 4 DOI: 10.1038/ncomms3685, site on 08/02/2014. </ref> <ref>Grundy SM (2004). "Obesity, metabolic syndrome, and cardiovascular disease". J. Clin. Endocrinol. Metab.89 (6): 2595–600. doi:10.1210/jc.2004-0372. PMID 15181029. </ref> <ref>Foster, W.R. and Burton, B.T.(1985). Health implication of obesity, Ann. Intern.Med., 103, 1024. </ref> <ref>Grunstein, R.R. and Widcox, I. (1994). Sleep-disordered breathing and obesity, Clin.Endocrinol.Metab. Baillier’s, 8, 601. </ref> <ref>Daugero, K.D. (2001). A new perspective on glucorticoid feedback: relation to stress, carbohydrate feeding and feeding behavior, J. Neuroendocrinol., 13, 1088. </ref> <ref>Larsson, B. et al (1984), Abdominal adipose distribution, obesity and risk of cardiovascular disease and death: 13 year follow up of participants in the study of men born in 1913, Br. Med. J., 288, 1401. </ref> <ref>Esposito K. et al (2004). "Effect of lifestyle changes on erectile dysfunction in obese men: A randomized controlled trial". JAMA, 291 (24): 2978–84. </ref>.

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==== Etiology, features, and consequences of ''atikrisha'' (emaciation) ====

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=== Etiology, features, and consequences of ''atikrisha'' (emaciation) ===

The etiological factors for ''atikrisha'' may be divided into two groups - excessive expenditure of calories and fewer intakes of calories. Either of these conditions leads to under-nutrition which ultimately results in ''atikrisha''. In the pathogenesis of ''krishata'', ''vayu'' plays an important role. Most of the etiological factors observed in the case of ''krisha'' and ''atikrisha'' provoke ''vata'' vitiation. Thus, vitiated ''vata'' may be considered the most important factor in the pathogenesis of ''krisha''. In ''sthaulya'' there is excessive formation and under-utilization (due to sedentary habit) of the ''rasa dhatu''. On the other hand, in ''krishata'' there is less formation of ''rasa'' due to diseases or due to undernourishment. Further, Charak and Sushruta both have categorized ''krishata'' as a ''rasa pradoshaja vyadhi'' (C.Su.28:10, Su.Su.15:37,24:8). In this way, ''rasa dhatu dushti'' mainly in the form of ''kshaya'' is found in extremely lean or emaciated people. The other ''dhatu'' involved in the pathogenesis of obesity as well as ''atikrisha'' is ''meda'' since it is mentioned that ''medokshaya'' (or the deficiency of ''meda'') cause ''krisanga'' (A.H.Su.11:18)<ref>Munshi, V.D. (translator) (1952). Ashtang Hridaya,Sastum Sahityavardhak Mudranalaya, Ahmedabad, India, p. 135, Sutrasthana-24/5, 11/18. </ref>.

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Obesity and leanness can manifest themselves in very severe and excessive forms than discussed here and those cases could make the management of such disorders - and any disease it could lead to – very challenging. While the principles of treatment remain unchanged, the therapeutic measures should be suitably intensified to counter the numerous disorders that arise because of excessive obesity and leanness (C.Su. 23/3-34). The patients of ''atikrisha'' and ''sthaulya'' perpetually suffer from diseases but the standpoint of treatment, the former is significantly more manageable because ''sthula'' (or the obese) suffers more in comparison to ''atikrisha'' (the emaciated) (Su.Su. 15:42). Further, it is mentioned that ''atikṛisha'' is a grave disease, but is considered better than ''atisthula'' from treatment aspect because there is no treatment for ''sthaulya''. For proper treatment of ''sthulya'' the drugs must have ''medohara, agnihara'' and ''vatahara'' action at the same time, which is neither possible from ''karshaṇa'' nor ''brimhana''. Recent evidence also suggests that Charak had associated extreme weight-loss/undernourishment with high rates of morbidity and mortality, although to a lesser extent than obesity<ref>Bose, Bholanoth (1877, 2009). A new system of medicine, entitled recognizant medicine; or, The state of the sick. London: J. & A. Churchill. pp. 192–199. Retrieved February 19, 2014. </ref> <ref>Lusky A, Barell V, Lubin F, Kaplan G, Layani V, Shohat Z, et al. Relationship between morbidity and extreme values of body mass index in adolescents. Int J Epidemiol 1996;25(4):829-834. </ref> <ref> </ref> <ref>Lake JK, Power C, Cole TJ. Women's reproductive health: the role of body mass index in early and adult life. Int J Obes Relat Metab Disord 1997;21(6):432-438. </ref> <ref> Kopp W, Blum WF, von Prittwitz S, Ziegler A, Lubbert H, Emons G, et al. Low leptin levels predict amenorrhea in underweight and eating disordered females. Mol Psychiatry 1997;2(4):335-340. </ref> <ref> He Q, Karlberg J. BMI in childhood and its association with height gain, timing of puberty, and final height. Pediatr Res 2001;49(2):244-251. </ref>.

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==== Management of the Morbidly Obese (20-28) ====

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=== Management of the Morbidly Obese (20-28) ===

In the conventional system of medicine, the main treatment for obesity consists of diet and physical exercise for short-term weight control. Maintaining the weight by short-term dietary control is very difficult to an obese person, and it required guided exercise and low calory diet in their daily regimens. Because lack of physical exercise is the key factor and imparts a role in the diathesis of obesity. 61 The lack of physical activities also plays an important role in obesity-associated with the involvement of brain and abdominal. Regarding physical exercise, it not only reduces body weight but also counteract metabolic adaptation but regulating nutritional balance set point.64 It is presumed that physical inactivity contributes to both visceral adiposity and cerebellar brain changes because in the area of cerebellar cortex and hippocampal dentate gyrus of brain show enhanced synaptogenesis and neurogenesis in response to physical exercise training.<ref>Matthias Raschpichler et al (2013). Abdominal fat distribution and its relationship to brain changes: the differential effects of age on cerebellar structure and function: a cross-sectional, exploratory study. BMJ Open. 2013; 3(1): e001915.Published online 2013 Jan 24. doi: 10.1136/bmjopen-2012-001915 </ref> <ref>McCarthyHD, EllisSM, ColeTJ. (2003): Central overweight and obesity in British youth aged 11–16 years: cross sectional surveys of waist circumference. BMJ, 326:624. </ref> <ref>GollischKS, BrandauerJ, JessenN, et al. (2009):Effects of exercise training on subcutaneous and visceral adipose tissue in normal- and high-fat diet-fed rats, Am J Physiol Endocrinol Metab; 297:E495–504. </ref>

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Recent evidence suggests that some ''ayurvedic'' herbal drugs are found to be very effective in normalizing deranged lipid profiles, reducing BMI and slowing down the risk heart diseases. Ayurvedic drugs such as ''rasona'' (Allium cepa), ''guggulu'' (Commiphora mukul), ''puṣhkaramula'' (Inula racemosa), ''arjuna'' (Terminalia Arjuna), ''dhānyaka'' (Coriandrum sativum), ''nishamalaki churṇa'' (powder of Emblica officinalis and Curcuma longa),''haritaki'' (Terminalia chebula), ''haridra'' (Curcuma longa), ''bilva'' (Aegle marmelos), ''tejapatra'' (Cinnamomum tamala), ''vrikshamla'' (Garcinia cambogia) and Ayurvedic formulations such as- ''triphala guggulu'', ''medohara guggulu'', ''amṛitadi guggulu'', ''arogyavardhani vaṭi'' etc. are also found to be effective in weight reduction as well as relief in other signs and symptoms. <ref name=ref1/> <ref name=ref2/> <ref name=ref3/><ref>Banerjee, S.K., Maulik, S.K. (2002): Effect of garlic on cardiovascular disorders: a review, Nutr.J, 1:4.</ref> <ref>Satyavati, G.V., Dwarakanath, C., and Tripathi, S.N. (1950 & 1969). Experimental studies on the hypocholesterolemic effect of Commiphora mukul (Guggulu), Indian J. Med. Res., 57, 1950, 1969. </ref> <ref>Karthikeyan, K. et al. (2003): Cardioprotective effect of the alcoholic extract of Terminalia arjuna bark in an invitro model of myocardial ischemic reperfusion injury, Iife Scince, 10, 73 (21):2727:39. </ref> <ref>Verghese, J. (2001): Coriander, Indian Spices, 38 (1):8. </ref> <ref>Kannan, V et al. (2012): Anti-diabetic activity on ethanolic extracts of fruits of terminalia chebula in Alloxan induced diabetic rats, American J. of Drug Discovery and Development, 2:135-142. </ref> <ref>Despande, U.R. (1966): Effect of Turmeric extract on lipid profile (1-22), Int.Seminar on free radicals medicated disease, 2-4. </ref> <ref>Kesari, A.N. et al. (2006): Hypoglycemic and anti-hyperglycemic activity of Aegle mormelas seed extract in normal and diabetic rats, J. Ethnopharmacol, 103 (3): 374-79. </ref> <ref>Sharma, S.R., Dwivedi, S.K., Swarup, D (1996): Hypoglycemic and hypolipidaemic effects of Cinnamomum tamala Nees leaves, Indian J Exp Biol, 34 (2): 216-220. </ref> <ref>Kohsuke Hayamizu, MS, Yuri Ishii, et al.( SE P T EMB E R / O C T O B E R 2003):Effects of Garcinia cambogia (Hydroxycitric Acid) on Visceral Fat Accumulation: A Double-Blind, Randomized, Placebo-Controlled Trial, current therapeutic research,VO L UME 64, No. 8, 551-567. </ref> <ref>Bhagwat, B.K. (1995). Triphala-guggul in Sthoulya in [[Ayurveda]] Research Papers III, Kulkarni, P.H., Ed., Ayurved Rasashala, Pune, India, p. 215 </ref> <ref>Vaidya, A.B. et al. (1980). A double-blind clinical trial of Arogyawardhini — an Ayurvedic drug- in acute viral hepatitis, Ind. J. Med. Res., 72, 588. </ref>

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==== Management of the emaciated/too lean (verse 29-34) ====

+

=== Management of the emaciated/too lean (verse 29-34) ===

Too lean patients are brought to good health through renourishment or reintroducing nourishing liquids and food to the body and check the process of catabolism. It starts with a glass of water followed by mixed with lemon and table salt and finally reach to juices, which is made up of vegetable, pulses, rice mixed with pepper, lemon juice and table salt. Later on, it is replaced with cow milk, soups of pulses and vegetable mixed with butter and salt. If the emaciated status is improved, try to introduced small amount of solid food in meals at the frequent interval and try to avoid a large amount of solid food at a time. The dietary regimen is to be focused on proteins, fats, carbohydrates, multi-vitamin and mineral for the management of the emaciated person. It is always kept in mind at the time of management of the too lean person, excessive fatty foods items and excess fiber dominated grains and vegetable are to be avoided because they are deficient in energy and consume too much time for digestion. Treatment of emaciation also includes prescribing a lot of sleep, rest, relaxation, and counseling. In the present context, ''rasa'' means body fluid which is responsible for the nourishment of entire body and mind. Impairment of circulation of body fluid results in diseases and decay. ''Rasa'' should be available in adequate quantity and quality for it to circulate through the cells of the body, providing the requisite nourishment they need for proper functioning.

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==== Sleep in general (verse 35) ====

+

=== Sleep in general (verse 35) ===

The age-old concepts of sleep (''nidra'') and its different stages such as ''jagrata'', ''swapana'' and ''sushupti'' are comparable to the current concept of sleep and its stages. The problems and pattern of sleep are assessed by observing the activity of brain through Electroencephalogram (EEG) pattern.<ref>Dement, William; Kleitman, Nathaniel (1 November 1957). "Cyclic variations in EEG during sleep and their relation to eye movements, body motility, and dreaming". Electroencephalography and Clinical Neurophysiology9 (4): 673–690. doi:10.1016/0013-4694(57)90088-3. PMID 13480240. </ref> It is pointed out that wakefulness and stages of sleep have a specific EEG pattern. The wakefulness is associated with Beta and Gama waves frequencies in EEG pattern, which depends on pleasurable or painful stressors of surrounding environment. Stage 1 non-rapid eye movement (NREM) sleep is characterized by slowing down of Beta and Gama wave frequencies, reached to slow down the Alpha wave, and finally reached to Theta wave frequencies in EEG pattern. At a higher stage of NREM and REM, these brain wave frequencies in EEG pattern gradually decreases, and the person falls into sleep. By observing overall brain activity in EEG pattern, we can say that frequencies of sleep waves are low in wakefulness and it is gradual increases in different stages of sleep. Sleep spindles and K-complexes appeared in EEG pattern in Stage 2 of sleep, while more sleep spindles are observed in Stage 3 of sleep. The slow wave sleep is also known as high amplitude Delta wave, which is commonly observed in Stages 3 and 4 of sleep in EEG pattern. Low amplitude, mixed frequency waves- a sawtooth wave in EEG pattern observed at REM stage of sleep.<ref> 71. BARKER, W; BURGWIN, S (1948 Nov-Dec). "Brain wave patterns accompanying changes in sleep and wakefulness during hypnosis." Psychosomatic Medicine10 (6): 317–26. PMID 18106841. </ref> <ref>Jankel, WR; Niedermeyer, E (January 1985). "Sleep spindles.". Journal of clinical neurophysiology: official publication of the American Electroencephalographic Society2 (1): 1–35. PMID 3932462. </ref> <ref>Loomis, A. L.; Harvey, E. N.; Hobart, G. A (1938). "Distribution of disturbance-patterns in the human electroencephalogram with special reference to sleep". Journal of Neurophysiology1: 413–430. </ref>

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==== Sleep regulation (verse 39-43) ====

+

=== Sleep regulation (verse 39-43) ===

It is presumed that the sleep physiology is controlled by the hypothalamus and the suprachiasmatic nucleus (SCN) in the brain, which regulates mechanism of homeostatic and circadian rhythm respectively of the body. The actual mechanism of the physiology of sleep is still evolving in biomedical sciences. The sleep is initiated and begins by projections from the SCN to the brain stem. Borbely called projections as Process S (homeostatic) and Process C (Circadian) respectively, who first proposed these two process models in 1982. He pointed out that maximum sleep is the outcome of significant differences between homeostatic and circadian rhythm.<ref name=ref74>Saper, Clifford B.; Scammell, Thomas E.; Lu, (Jun (27 October 2005)): "Hypothalamic regulation of sleep and circadian rhythms". Nature437 (7063): 1257–1263. doi:10.1038/nature04284. PMID 16251950.</ref>

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==== Effects of sleep (verse 36-38 and 44-49) ====

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=== Effects of sleep (verse 36-38 and 44-49) ===

Recent conventional evidence suggests that seasonal variation can have an impact on sleep/wake cycle, which is quite interesting and proven the age-old concept of [[Ayurveda]]. Recent evidence shows that core temperature of body and secretion of melatonin hormone levels are slightly greater in the month of summer due to prolong the length of light exposure, which imparts significant role in daytime sleep in summer. This is the reason people go to bed early at night and wake up early in the morning in the month of summer. Sunlight exposure in the morning hours may affect internal biological clock, shifting the timing of the sleep window. The need and function of sleep are the most lacking areas of sleep research in biomedical sciences. Some of the important ones are- restoration and recovery of body systems, energy conservation, memory consolidation, protection from predation, brain development, and discharge of emotions.<ref name=ref74/> <ref>Krueger, James M.; Obál, Ferenc; Fang, Jidong. "Why we sleep: a theoretical view of sleep function". Sleep Medicine Reviews3 (2): 119–129. doi:10.1016/S1087-0792(99)90019-9. </ref> <ref>KRUEGER, JAMES M.; OBÄL, FERENC (1 June 1993). "A neuronal group theory of sleep function". Journal of Sleep Research2 (2): 63–69. doi:10.1111/j.1365-2869.1993.tb00064.x. </ref> <ref>Friborg, O., Bjorvatn, B., Amponsah, B., Pallesen, S. (2012). Associations between seasonal variations in day length (photoperiod), sleep timing, sleep quality and mood: a comparison between Ghana (5°) and Norway (69°). Journal of Sleep Research, 21(2), 176-184.) </ref>

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==== Sleep about ''atisthula'' and ''atikrisha'' (verse 51) ====

+

=== Sleep about ''atisthula'' and ''atikrisha'' (verse 51) ===

Recent evidence suggests that a good sleep plays an important role in the regulation of neuroendocrine, hormonal and metabolic function in the body. Since last few decades, the timing and quality of sleep is gradually hampered due to the affliction of modernization in many ways. At present, the adult and children progressively reduce bedtimes and increases times for other activities, which affect the metabolic functions in many ways. The ''atisthula'' and ''atikrisha'' are also the outcome of excessive sleep and lack of sleep and vice-versa. Evidence shows that sleep loss for prolong period may provoke the risk of weight gain and morbid obesity. Further, sleep reduction in young adults affects metabolic and endocrine functions in various ways such as- insulin resistance, hyperglycemia, elevated sympathovagal activity, an elevated level of serum glucocorticoid hormone, increased levels of ghrelin, and decreased the level of leptin. Due to improper and lack of good quality of sleep in adolescents may be important factors to consider in the prevention of childhood obesity.<ref>Neeraj K. Gupta,William H. Mueller,Wenyaw Chan, Janet C. Meininger (2002).: Is obesity associated with poor sleep quality in adolescents?. Am. J. Hum. Biol.; 14:762–768, 2002. </ref> Probably this is the reason that sleep is mentioned in ''ashṭoninditiya'' chapter by Charak about ''atisthula'' and ''atikrisha'' like other dietary and lifestyle intervention.

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==== Insomnia or sleeplessness (verse 52-54) ====

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=== Insomnia or sleeplessness (verse 52-54) ===

''Anidra'' of [[Ayurveda]] is closely related to Insomnia, or sleeplessness of biomedical sciences. It is a disorder of sleep in which a person is unable to fall in sleep. Nowadays, insomnia is an important area of clinical practice to seek the attention of the physician because a large number of patients come to the hospital suffering from insomnia as secondary conditions. It is sometimes a functional impairment during awake, which may occur at any age, but it is particularly common in the elderly. Insomnia is either short-term lasting up to 3 hours, or it may be long term lasting for > 3 hours. It may lead to developing dementia, lack of concentration, depression, mental irritation and increases the risk of cardio-vascular accidents along with increases the chances of a roadside accident. <ref>Roth, T. (2007). "Insomnia: Definition, prevalence, etiology, and consequences". Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine3 (5 Suppl): S7–10. </ref> <ref>Wilson, Jennifer F. (2008). "Insomnia". Annals of Internal Medicine148: ITC1. doi:10.7326/0003-4819-148-1-200801010-01001 </ref> Regarding its management some drug such as valerian extract has undergone multiple studies and appears to be moderately effective. Similarly, L-Arginine L-aspartate, S-adenosyl-L-homocysteine, and delta sleep inducing peptide (DSIP) appear to be significantly effective in the cases of insomnias.<ref>Morin, C. M.; Koetter, U.; Bastien, C.; Ware, J. C.; Wooten, V. (2005). "Valerian-hops combination and diphenhydramine for treating insomnia: A randomized placebo-controlled clinical trial". Sleep28 (11): 1465–1471. </ref> <ref>Meolie, A. L.; Rosen, C. et al.: Clinical Practice Review Committee; American Academy of Sleep Medicine (2005). "Oral nonprescription treatment for insomnia: An evaluation of products with limited evidence". Journal of clinical sleep medicine: JCSM: official publication of the American Academy of Sleep Medicine1 (2): 173–187. PMID 17561634. </ref>

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The concept of ''Nidra'' in [[Ayurveda]] is quite comparable to the sleep of biomedical sciences. The ''nidra'' is so important for the maintenance of health and sustaining the life. This is true in the light of contemporary scientific knowledge too. According to [[Ayurveda]], ''kapha'' and ''tamas'' are responsible for ''nidra'' even as modern studies attribute the occurrence of sleep to many factors including stimulation of certain areas of the brain. [[Ayurveda]] classifies the ''nidra'' based on the mode of origin while modern classification of sleep based on physiological variations seen in association with the different types of sleep. Some factors like food, activities, external stimuli, etc. affect ''nidra'' or sleep. Any variation in the normal sleep pattern is not at all desirable, and they may cause serious health problems that demand proper medical attention.

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==== Conclusion ====

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=== Conclusion ===

The present chapter reveals that the clinical entity, consequences, and management of too obese, too lean, insomnia, along with categorization of good built, information and mechanism of sleep and measures to induce good sleep was fairly well known even in the classical period of [[Ayurveda]], which is comparable to the latest development in this field. The Ayurvedic classics vividly describe the etiological factors, pathogenesis, clinical presentation, complications and its categories and treatment modalities of too obese, which has a striking resemblance to the latest development in this field. The ''samprapti'' (pathogenesis) of this disease is based on the specific ''dosha-dushya'' pattern. Besides, the special emphasis placed on vitiation of ''medas''. The age-old ideas are now getting strong scientific support for the emerging concept of prediabetes, insulin resistance, and metabolic syndrome, signifying the role of lipid disorders in the pathogenesis, hypometabolic state (''ama'' state) and immunodeficiency in these disorders. Numbers of complications have been described in this context including ''prameha'', GI problems, skin disorders, etc. It is presumed that in the diathesis of complications, impaired status of ''agni, ojas'' and ''medas'' play an important role6.

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On The overall assessment, the concept of overweight and obesity, emaciation, sleep and its type, indications, and contraindications of day sleep, the role of sleep in obesity, causes of insomnia and features of good and bad sleep along with features of good body built was a well-known entity since antiquity. The available descriptions appear very contemporary and scientific. Certain therapeutic modalities have close resemblance with several non-drug approaches of modern medicine. These modalities can be combined judiciously for individualized prevention and cure of too obese, too lean and insomnia. The current approaches and management of too obese and too lean along with insomnia are still not satisfactory in the conventional system of medicine; this chapter provides a new outlook to scholars and researchers of [[Ayurveda]], which is based on current publications and reports.

</div>

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===References===

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==References==

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~~=== Glossary ===~~

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*अतिदीर्घ (atidirgha)- too tall

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*अतिह्रस्व (atihrasva)- too short

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*अतिलोमा (atiloma)- too hairy

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*अलोमा (aloma)- hairless

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*अतिकृष्ण (atikrishna)- too black

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*अतिगौर (atigaura)- too white

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*अतिस्थूल (atisthula)- too obese

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*अतिकृश (atikrisha)- too lean

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*जवोपरोधः (javoparodhaḥ)- hampered movement.

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*कृच्छ्रव्यवायता (krichchhravyavayata )- difficulty in sexual intercourse

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*मेदसाऽऽवृतमार्गत्वाद्वायुः (medasa-avritamargatvadvayuḥ)- medas obstruct the channels of vāta

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*वनदावो वनं (vanadavo vanaṁ)- as the forest fire burns the forest.

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*विकारान् दारुणान् (vikaran darunan)- diseases of very serious types.

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*प्रमिताशनम् (pramitashanam)- intake of food in inadequate quantity

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*लङ्घनं (laṅghanaṁ)- fasting

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*क्रियातियोगः (kriyatiyogaḥ)- over the use of therapeutic measures.

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*धमनीजालसन्ततः (dhamanījalasantataḥ)- prominent vascular network.

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*सममांसप्रमाण (samamaṁsapramaṇa)- having balanced proportion of muscles.

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*समसंहनन (samasamhanana)- having balanced compactness of the body

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*दृढेन्द्रिय (dridhendriya)- very strong sensory and motor systems including the mind.

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*समपक्ता (samapakta)- digest properly.

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*समजरः (samajaraḥ)- assimilate properly.

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*सन्तर्पण (santarpaṇa): Nourishing therapy.

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*व्यायाम (vyayamaṁ)- physical and mental exercise.

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*व्यवाय (vyavaya)- sexual act

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*सुखं (sukhaṁ)- happiness

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*दुःखं (duḥkhaṁ)- misery

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*पुष्टिः (puṣhṭiḥ)- nourishment

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*कार्श्यं (karshyaṁ)- emaciation

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*बलाबलम् (balabalam)- strength and weakness.

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*वृषता (vrishata)- potency

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*क्लीबता (klibata)- impotence

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*ज्ञानमज्ञानं (jñanamajñanaṁ)- intellect and non-intellect.

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*सत्याबुद्धि (satyabuddhi)- real or true knowledge.

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*धातुसाम्यं (dhatusamyaṁ)- equilibrium of dhātus.

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*दूषीविष (dushīvisha)- forms of latent poisons.

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*अङ्गमर्द (aṅgamarda)- malaise

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*गलामय (galamaya)- disorders of throat

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*पीनस (pinasa)- rhinitis

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*rन्द्रा (tandra)- drowsiness

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*हलीमकः (halimaka)- advance stage of jaundice.

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*mत्सादन (utsadana)- unction

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*ग्राम्यानूपौदक रस (gramyanupaudaka rasa)- meat soup of animals residing in domestic, marshy and aquatic areas

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*संवाहन (saṁvahana)- rubbing of the body by hand.

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*रक्तमोक्षण (raktamokṣhaṇa)- bloodletting.

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*तमोजयः (tamōjayaḥ)- suppression of tamas.

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*भूतधात्री (bhutadhatri)- nurses all the living beings.

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